Effecting Changes in Physician Attitudes
Following, below, is a dialogue from a Pain Discussion group in which many expert physicians and pain patients are enrolled. It is a very useful discussion.
The National Foundation for the Treatment of Pain
Margo M, RN MS wrote:
I have been asked to help locate a physician or
multidisciplinary pain program for a woman (probably in her 50s) who has had two back surgeries over 5 years, last one in Sept. 2002. In past few months she has developed escalating, severe pain and is suicidal. She nearly succeeded in killing herself and was admitted to psych for 2 days.
(Her) Physician has no plan for pain management, is hostile toward patient, and accuses her of "drug
seeking." She lives in Bandon, OR, but is willing to go anywhere in Oregon or California to get help. I guess it's pretty obvious that she needs
immediate evaluation of the cause of her escalating pain and pain relief.
Can anyone recommend a physician or pain program in
Oregon or California?
Thank you very much.
"J.S.Hochman MD" wrote:
I am sending this on to Mr. Gordon, who will send her a list of qualified referrals in Oregon. If none will provide adequate care we can find her someone in California. The question is where in California
would she be willing to go?
From: Mary Baluss
Subject: Re: [PAIN_CHEM_DEP] Referral in Oregon -
Don't forget to counsel the patient/family to file a state medical board complaint!
"J, Carmen" wrote:
I have met so many patients who have not been able
to receive appropriate care from physicians. The problem is rampant. What does the state medical
board do with such a complaint? If there are no
physicians willing to take on pain management, who do the boards discipline? So far, all we hear is
about the physicians the boards discipline for
trying to DO pain management. What power do the boards have over physician apathy and denial?
If I could throw my two-cents in here. I have worked on this issue in Michigan for sometime. The short answer is not much! If one refuses to do something and it is legal to so refuse, their is not much a person can do, except sue. Most chronic pain patients are in no position to sue, and to be honest, I'm not sure its the best way to address the problem (although it probably would go a long way to eliminate frustration).
The medical boards need to do more. The Legislature
needs to do more. And EDUCATION NEEDS TO BE MORE.
Here in Michigan, a committe I was on that our (now)X-Governor appointed and set up to study the issue, mainly under the "end of life" premise (mainly due to Kevorkian's murders) and the best we could come up with was REQUIRING PAIN MANAGEMENT COURSES to RENEW A MEDICAL LICENSE! We didn't want to go sue happy and I am somewhat confident that this approach would do much more damages than good. So, I subscribe and advocate required education in state-of-the-art pain management and what we have learned in the past few years about painm, meds, and chronic pain management. Just showing ourselves to some of the nay-sayers had quite an impact as some of the Doctors on the panel could not believe I was walking, talking, and functioning on such "mega-doses" (they said) of opiates! Indeed, it
was eye widening when I noted my then dose of
I think what we are facing here is the inertia of ignorance, propelled by fear. Doctors face a VERY real threat of prosecution/persecution if they prescribe opioids. According to data from the National Practitioners Data Bank, doctors face a 1/1200 likelihood of being prosecuted by the DEA if they prescribe opioids. This is a career destroying prospect accompanied by financial ruin.
I agree that confronting actual intractable pain patients who are able to function because of opioids is one of the most powerful forces in inducing change in attitude and belief among doctors. I know of several such patients who have served on task forces (and the like) who report precisely this kind of impact on physician and law enforcement fellow members. This kind of process of change is far too limited and slow, however, to offer any real solution to the current opiophobia.
Education is an approach being tried in California, where doctors are now required to take 12 hours of CME on pain management to renew their licenses. I believe that this will help replace ignorance with scientifically defensible truths about pain treatment. But whether it will actually change physician behavior (without a major change in the enforcement/regulatory situation) is yet to be seen.
Faced with this situation, the National Foundation for the Treatment of Pain has initiated Pain Practice Liability Insurance. Physicians who wish to practice pain management can obtain $250,000 in legal defense against any form of prosecution related to pain practice ( for about $1800/year). Mary Baluss heads up the legal defense team for the insurance company, which eliminates the horrible expense to physicians of having to pay the cost of educating an attorney in this still relatively arcane area of the law. Most importantly, the contract of insurance includes a standard of care and record keeping, to which the insured must conform. The insurance established a Professional Advisory and Review Committee (the PARC), that reviews all claims under the insurance to determine if the Standards were met and that no credible evidence of criminal intent or behavior was involved. If these criteria are met the insurance company uses its full resources to defend the doctor. We believe this will be a "1000 pound gorilla" on the side of the doctors. The quality of the expertise on the committee is such that their conclusion will be virtually impossible for prosecutors to overcome with expert witness of their own (which they will have to do to secure a conviction.)
The insurance initiative can be reviewed (and applied for) at http://www.uprrg.com
JS Hochman, M.D.